Babies got heart valves from donor with cancer

FOUR Queenslanders, including three babies, received heart valves from a donor with an aggressive brain tumour after a medical director who authorised acceptance of the tissue was not given full details of the cancer.

The Courier-Mail revealed a damning review into the Queensland Heart Valve Bank found a breakdown of quality control processes led to the blunder, which has "raised questions about the safety of tissue remaining in storage".

Doctors perform a heart valve transplant. Picture: Jackson Flindell

"Investigators have considered that the clinical policy review practices of the Queensland Heart Valve Bank are below an acceptable standard and that there was a clear failure of clinical governance," a Queensland Health summary of the review says.

Although the independent external review found the risk to the patients was "low to nil", Health Minister Steven Miles will today announce tissue banks across the state will be merged into one to improve accountability and quality assurance.

It's understood disciplinary action is underway regarding two staff linked to the Queensland Heart Valve Bank, who have been the subject of other allegations.

In May, an audit of the bank's records revealed that four patients received heart valves from a donor who died from gliosarcoma, a type of brain cancer.

It’s understood disciplinary action is underway regarding two staff linked to the Queensland Heart Valve Bank, who have been the subject of other allegations. Picture: Jackson Flindell

A review, co-ordinated by Australian Commission on Safety and Quality in Health Care, into how the heart valves were accepted for transplantation found the Queensland Heart Valve Bank's medical director was "not provided with the full donor file".

The Courier-Mail understands that although the file revealed the heart valves had been removed from a patient with brain cancer, the medical director was unaware the donor had gliosarcoma, a rare and aggressive tumour that would have prevented the tissue being accepted by the bank.

A departmental summary of the review's findings said the tissue was "accepted in breach" of Queensland Heart Valve Bank procedures.

A The Courier-Mail story from June 23, 2018

The full report would not be released publicly because it contained sensitive patient information and details that would allow people to identify specific staff members.

Chief Health Officer Sonya Bennett said Queensland Health would implement all of the review's recommendations.

Under those recommendations, advice must be sought from Australia's medicines regulator, the Therapeutic Goods Administration, before tissue still being stored by the Queensland Heart Valve Bank can be used for implantation.

Mr Miles told The Courier-Mail a new tissue bank for all donor tissue, including heart valves, would be created under a single and accountable management structure after the review.

"I asked for this investigation not just to get to the bottom of what went wrong but also to find out how we could deliver even better tissue bank services," he said.